Organization
MAIN STREET PHARMACY 4 LLC
Active
Other names
Main Street Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
JEAN JACOB (OWNER)
(203) 870-9902
Entity
Organization
Contact information
Practice address
166 W BROAD ST, STAMFORD, CT 06902-3661
(203) 870-9902
(203) 870-9903
Mailing address
166 W BROAD ST, SUITE# G1, STAMFORD, CT 06902-3661
(203) 883-8700
(203) 883-8702
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PCY.0002185
CT
3336C0004X
Compounding Pharmacy
—
—
3336S0011X
Specialty Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0722062
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
08/12/2010
Last updated
08/23/2011
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